Community Strategies:Angelo Maroun

Abington, Carver, Kingston, Leominster Pleasant Street, Leominster Wachusett Street, Middleboro, and Winchendon Alger Street

Comprehensive Program ReviewOctober 19, 2012

Lowlights/Challenges: Overtime across the cluster is high Performance evaluation numbers not as favorable

compared to last CPR Financial Audits missed, stealing in Leominster Loss of managers and seasoned staff Medication occurrences, an increase since last CPR Distance, new cluster is much more spread apart

STAFFING

Staff Turnover RatesPerformance Evaluations

Staff Training

STAFF TURNOVER RATES9/1/2011-8/31/2012

The current Cluster Average is 20.9% compared to the CSMA average of 21.1% Last CPR, Cluster Average was 25.4% versus CSMA overall of 27.8% Please note that the CS Cluster configuration has changed since the last CPR

Data obtained from HR Reports

Action Plan Item

OVERDUE PERFORMANCE EVALUATIONS March 2012 - August 2012

Total of 66 FTE’s and 34 PTE’s with overdue performance evaluations between March 2012 – August 2012. Most overdue evaluations were completed within one month of due date.

Last CPR had a total of 18 FTE’s and 17 PTE’s with overdue performance evaluations from June 2011 - November 2011. Please note: CS Cluster included Abington, Bellingham, Carver, Franklin, Kingston, Medway, Middleboro, Wachusett and Wrentham

Abington, Carver, Kingston, Wachusett and Middleboro: (March - August 2012) = 47 FTE’s and 20 PTE’s overdue compared to last CPR: (June – November 2011): 15 FTE’s and 5PTE’s overdue.

Data obtained from HR Department & HR Personnel Summary

March April May June July August

FT PT FT PT FT PT FT PT FT PT FT PT

Abington 2 0 2 0 1 0 1 0 1 1 0 1

Carver 3 0 3 0 1 1 1 1 1 1 0 1

Kingston 0 0 0 0 0 0 0 0 0 1 1 1

Middleboro 2 0 0 2 0 0 0 0 0 0 0 0

Pleasant 5 3 5 2 1 1 1 2 1 2 1 2

Wachusett 2 1 4 1 5 1 6 1 6 2 5 2

Alger 3 1 2 0 0 0 0 1 0 1 0 1

Cluster - Totals 17 5 16 5 8 3 9 5 9 8 7 8

Overdue Evaluations

2 > or more months

FT PT

Abington 1 1

Carver 2 1

Kingston 0 0

Middleboro 0 0

Pleasant 1 2

Wachusett 5 2

Alger 0 1

Cluster - Totals 9 7

Action Plan Item

Total 2,659 training hours were completed March – August 2012; average of 37.9 hours per staff/cluster/over six months Average training hours per staff/month = 6.3 hours Last CPR, total training hours = 2,942 (CS Cluster included Abington, Bellingham, Carver, Franklin, Kingston, Medway, Middleboro, Wachusett and Wrentham)

Data obtained from MMRs and HR Reports

Action Plan Item

CLIENT RELATED

• Clinical Hours• Walk-Aways• Medication• De-escalation and Restraints• Mainstream/Community Inclusion Activities

Cluster Average of 1.6 clinical hours per client/month Total Clinical Hours = 319 (March – August 2012) Last CPR, the cluster average of clinical hours per client/month was 2.6

(June – November 2011); please note that the CS Cluster configuration has changed.

Data obtained from MMRs

Client Walk-Aways

March – August 2012 June – November 2011

Abington 1 0

Carver 0 2

Kingston 0 0

Pleasant 1 N/A

Middleboro 0 0

Wachusett 0 0

Alger 0 N/A

Cluster - Total 2 2

Please note: CS Cluster configuration has changed from last CPR

Data obtained from MMRs

Average: 0.33 medication incidents and occurrences per client/month Total of 72 medication incidents and occurrences (March – August 2012) The majority of the medication incidents/occurrences (90.3% or 65/72) were client refusal of medications Last CPR, a total of 34 medications incidents and occurrences. CS Cluster configuration has changed since last CPR. Data obtained from MMRs

Action Plan Item

De-Escalations : Restraints

March – August 2012 June – November 2011

Abington 132:0 121:0

Carver 44:1 24.3:1

Kingston 372:0 181:1

Pleasant 3.1:1 N/A

Middleboro 177:0 93:0

Wachusett 98:1 12.6:1

Alger 34:1 N/A

Cluster Average 4,102 De-escalations:239 Restraints

or 17.2:1

83.9:1

Please note: CS Cluster configuration has changed since last CPR

Data obtained from MMRs

Average Community Inclusion Activities Participated In and Offered Per Client/ Month (March – August 2012)

Average of 11 Inclusion Activities Per Client/Month (86% participation rate) Last CPR, average of 4.4 inclusion activities participated in per client/ month (71% participation rate). Please note that Cluster configuration has changed since last CPR. Data obtained from MMRs

Average Mainstream Activities Participated In and Offered Per Client/ Month (March – August 2012)

Average of 16.6 Mainstream Activities Participated in Per Client/Month (87.4% participation rate) Last CPR, average of 16.3 mainstream activities participated in per client/ month (79% participation rate). Please note that CS Cluster configuration has changed since last CPR.

Data obtained from MMRs

Quality Assurance

Key MMR Results

Monitoring Results

Employment/Education: ( As of August 31, 2012) 7/33 or 21% of the residents are competitively employed 18/33 or 55% of the residents are in meaningful day 8/33 or 24% of the residents are in a sheltered workshop 6/33 or 18% of the clients are enrolled in pre-vocational training programs

Other: 28/33 or 85% of the residents chose healthy living opportunities in programs 1 Contraband (Trigger) item found in the programs over this time period; last CPR =

3 Contraband items found

Staff Certifications: 100% of staff are current in the following certifications: PAC/CPI; FA/CPR/AED;

Human Rights; Fire Safety 67% of the staff are MAP certified

o Abington 50%; Carver 59%; Kingston 71%; Pleasant 67%; Middleboro 67%; Wachusett 75%; and Alger 86%

Positives• Average Scores

– Confidential Files = 82%– Financial Records = 91 % (Pleasant Street is not included in this number)– Program Forms = 88%

• Strengths of the Cluster– ISP Paperwork (Assessment and Provider Support Strategies)– Fire Drills and Safety Plans– Mandatory Medical Appointments

Areas In Need of Improvement– Data tracking of the Restraints and LOM (Limitation of Movement) forms– Required signatures for Skills Management Plans, Consent forms and LOM forms– ISP Paperwork (Progress Summaries)

Action Plan Item

• See Handout